Imaging of Acute Lung Injury - Thoracic Rad Lung Injury Sujal R Desai King s College Hospital,...
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188 SUNDAY The Imaging of The Imaging of The Imaging of The Imaging of Acute Lung Injury Acute Lung Injury Sujal R Desai Sujal R Desai King s College Hospital, London King s College Hospital, London Imaging tests vital in Ix of lung injury Background • Increased numbers of patients surviving • Plain CXR both common and vital; CT and other tests providing a supportive “problem-solving” role • Further insights from CT…? Aims • Consider (briefly) the “basic” radiological aspects of imaging critically ill-patients • Review the specifics of imaging in acute lung injury (ALI) & acute respiratory distress syndrome (ARDS) • Discuss the value of and pathophysiological insights from CT (± other imaging tests) in ALI & ARDS Chest Radiography on ICU Chest Radiography on ICU The Benefits of Digital Radiography The Benefits of Digital Radiography Chest Radiography on ICU Chest Radiography on ICU The Benefits of Digital Radiography The Benefits of Digital Radiography Imaging on the ICU Imaging on the ICU The Issue of the Routine Chest Radiograph The Issue of the Routine Chest Radiograph Imaging on the ICU Imaging on the ICU The Issue of the Routine Chest Radiograph The Issue of the Routine Chest Radiograph • A daily routine in many units A daily routine in many units • Important for Important for • Detection of complications Detection of complications • Monitoring progress Monitoring progress • 15 15-65% show clinically unsuspected changes / 65% show clinically unsuspected changes / progression progression 1 Henschke CI Bedside chest radiography: diagnostic efficacy Radiology 1983;149:23-26 2 Strain DS Value of routine daily chest x-rays in the medical intensive care unit. Crit Care Med 1985;13:534-536 Imaging on the ICU Imaging on the ICU The Issue of the Routine Chest Radiograph The Issue of the Routine Chest Radiograph Imaging on the ICU Imaging on the ICU The Issue of the Routine Chest Radiograph The Issue of the Routine Chest Radiograph Day 1 Day 5 Imaging of Acute Lung Injury Sujal R. Desai, MBBS, MD ESTI SPEAKER
Transcript of Imaging of Acute Lung Injury - Thoracic Rad Lung Injury Sujal R Desai King s College Hospital,...
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The Imaging ofThe Imaging ofThe Imaging of The Imaging of Acute Lung InjuryAcute Lung Injury
Sujal R DesaiSujal R DesaiKing s College Hospital, LondonKing s College Hospital, London
Imaging tests vital in Ix of lung injury
Background
• Increased numbers of patients surviving
• Plain CXR both common and vital; CT and other tests providing a supportive “problem-solving” role
• Further insights from CT…?
Aims
• Consider (briefly) the “basic” radiological aspects of imaging critically ill-patients
h f f l• Review the specifics of imaging in acute lung injury (ALI) & acute respiratory distress syndrome (ARDS)
• Discuss the value of and pathophysiological insights from CT (± other imaging tests) in ALI & ARDS
Chest Radiography on ICUChest Radiography on ICUThe Benefits of Digital RadiographyThe Benefits of Digital RadiographyChest Radiography on ICUChest Radiography on ICUThe Benefits of Digital RadiographyThe Benefits of Digital Radiography
Imaging on the ICUImaging on the ICUThe Issue of the Routine Chest RadiographThe Issue of the Routine Chest RadiographImaging on the ICUImaging on the ICUThe Issue of the Routine Chest RadiographThe Issue of the Routine Chest Radiograph
•• A daily routine in many unitsA daily routine in many units
•• Important for Important for
•• Detection of complicationsDetection of complications
•• Monitoring progressMonitoring progress
•• 1515--65% show clinically unsuspected changes / 65% show clinically unsuspected changes / progressionprogression
1 Henschke CI Bedside chest radiography: diagnostic efficacy Radiology 1983;149:23-262 Strain DS Value of routine daily chest x-rays in the medical intensive care unit. Crit Care Med 1985;13:534-536
Imaging on the ICUImaging on the ICUThe Issue of the Routine Chest RadiographThe Issue of the Routine Chest RadiographImaging on the ICUImaging on the ICUThe Issue of the Routine Chest RadiographThe Issue of the Routine Chest Radiograph
Day 1 Day 5
Imaging of Acute Lung InjurySujal R. Desai, MBBS, MD ESTI SPEAKER
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Imaging in Lung InjuryImaging in Lung InjurySome Key QuestionsSome Key QuestionsImaging in Lung InjuryImaging in Lung InjurySome Key QuestionsSome Key Questions
• What is/are the principal roles of CXR, CT, US in the management of patients with ALI/ARDS?in the management of patients with ALI/ARDS?
• Does CT add anything…?
• Is there any prognostic information in imaging tests?
Imaging in Lung InjuryImaging in Lung InjurySome Key QuestionsSome Key QuestionsImaging in Lung InjuryImaging in Lung InjurySome Key QuestionsSome Key Questions
• What is/are the principal roles of CXR, CT, US in the management of patients with ALI/ARDS?in the management of patients with ALI/ARDS?
• Does CT add anything…?
• Is there any prognostic information in imaging tests?
Imaging in Lung InjuryImaging in Lung InjuryPrincipal Roles of Radiological TestsPrincipal Roles of Radiological TestsImaging in Lung InjuryImaging in Lung InjuryPrincipal Roles of Radiological TestsPrincipal Roles of Radiological Tests
• Diagnosis
• Monitoring progress / resolution
• Detection of (clinically-unsuspected) complications
The Diagnosis of ALI/ARDSThe Diagnosis of ALI/ARDSThe Diagnosis of ALI/ARDSThe Diagnosis of ALI/ARDS
ALI & ARDSALI & ARDSAn Historical PerspectiveAn Historical PerspectiveALI & ARDSALI & ARDSAn Historical PerspectiveAn Historical Perspective
12 patients, varied insults Trauma n=7 Infection n=4 Acute Pancreatitis n=1
• Breathlessness• Refractory hypoxia• Reduced compliance• CXR infiltrates
1 Ashbaugh DG et a.l Acute repiratory distress in adults Lancet 1967;2:319-323
ALI & ARDS ALI & ARDS Current Diagnostic (Physiological) DefinitionsCurrent Diagnostic (Physiological) DefinitionsALI & ARDS ALI & ARDS Current Diagnostic (Physiological) DefinitionsCurrent Diagnostic (Physiological) Definitions
ALI ARDS
Timing Acute AcuteTiming Acute AcutePaO2 / FiO2 300 200CXR Bilat diffuse Bilat diffusePAWP 18 18
1 Bernard et al. The American-European consensus conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination Am J Respir Crit Care Med 1994;149:818-824
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ALI & ARDSALI & ARDSPathologicalPathological--Radiological FindingsRadiological FindingsALI & ARDSALI & ARDSPathologicalPathological--Radiological FindingsRadiological Findings
EXUDATIVE PROLIFERATIVE FIBROTIC
DIFFUSE ALVEOLAR DAMAGE
ALI & ARDSALI & ARDSPathological Pathological Radiological FindingsRadiological FindingsALI & ARDSALI & ARDSPathological Pathological Radiological FindingsRadiological Findings
EXUDATIVE PROLIFERATIVE FIBROTIC
ALI & ARDS ALI & ARDS AetiologyAetiologyALI & ARDS ALI & ARDS AetiologyAetiology
PULMONARY
A i tiA i ti
EXTRA-PULMONARY
AspirationAspirationInfection (Infection (bacterial, viral, bacterial, viral, PCPPCP))
NearNear--drowningdrowningToxic fume inhalationToxic fume inhalationLung contusionLung contusion
Systemic SepsisSystemic Sepsis(Non(Non--thoracic) traumathoracic) trauma
Hypertransfusion (TRALI)Hypertransfusion (TRALI)Cardiopulmonary bypass (rare)Cardiopulmonary bypass (rare)
1 Bernard et al. The American-European consensus conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination Am J Respir Crit Care Med 1994;149:818-824
ARDS ARDS Variable CT AppearancesVariable CT AppearancesARDS ARDS Variable CT AppearancesVariable CT Appearances
Desai SR et al. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary injury: a comparative CT study Radiology 2001;218:689-693
TYPICALATYPI CAL
ARDS ARDS Variable CT AppearancesVariable CT AppearancesARDS ARDS Variable CT AppearancesVariable CT Appearances
Desai SR et al. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary injury: a comparative CT study Radiology 2001;218:689-693
ARDS ARDS Variable CT AppearancesVariable CT AppearancesARDS ARDS Variable CT AppearancesVariable CT Appearances
EXTRAPULMONARYPULMONARY
TYPICALATYPI CAL
Desai SR et al. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary injury: a comparative CT study Radiology 2001;218:689-693
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ARDS ARDS Pulmonary versus Extrapulmonary ARDSPulmonary versus Extrapulmonary ARDSARDS ARDS Pulmonary versus Extrapulmonary ARDSPulmonary versus Extrapulmonary ARDS
EXTRA PULMONARYPULMONARY
Desai SR et al. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary Injury: A Comparative CT Study Radiology 2001;218:689-693
ARDS ARDS Unilateral ARDSUnilateral ARDSARDS ARDS Unilateral ARDSUnilateral ARDS
Padley SPG et al. Asymmetric ARDS following pulmomary resection: CT findings initial observations Radiology2002;223:468-473
Monitoring ProgressMonitoring ProgressMonitoring ProgressMonitoring ProgressMonitoring ProgressMonitoring Progress
Detection of ComplicationsDetection of Complications
Monitoring ProgressMonitoring Progress
Detection of ComplicationsDetection of Complications
Imaging in ALI/ARDSImaging in ALI/ARDSRecurrent Pneumothorax and Chest DrainsRecurrent Pneumothorax and Chest DrainsImaging in ALI/ARDSImaging in ALI/ARDSRecurrent Pneumothorax and Chest DrainsRecurrent Pneumothorax and Chest Drains
47 PneumthoracesARDS=21; non-ARDS=26
1 Heffner JE et al Recurrent penumothoraces in ventilated patients despite ispilateral chest tubes Chest 1995;108:1053-1058
ARDS14/21 recurrent
Non-ARDS2/26 recurrent
HORIZONTAL TUBE12/14 ARDS; 2/2 non-ARDS
Imaging in ALI/ARDSImaging in ALI/ARDSMalpositioned Chest Drains a few examples!Malpositioned Chest Drains a few examples!Imaging in ALI/ARDSImaging in ALI/ARDSMalpositioned Chest Drains a few examples!Malpositioned Chest Drains a few examples!
Imaging in Lung InjuryImaging in Lung InjurySome Key QuestionsSome Key QuestionsImaging in Lung InjuryImaging in Lung InjurySome Key QuestionsSome Key Questions
• What is/are the principal roles of CXR, CT, US in the management of patients with ALI/ARDS?in the management of patients with ALI/ARDS?
• Does CT add anything…?
• Is there any prognostic information in imaging tests?
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Imaging in ALI/ARDSImaging in ALI/ARDSQuantification of data on CT imagesQuantification of data on CT imagesImaging in ALI/ARDSImaging in ALI/ARDSQuantification of data on CT imagesQuantification of data on CT images
KEY PRIN CIPLES
Dens ity
CT Dens ity of lun g dete rmine d by relative am ount of air
Air on CT is black
Decrease in r elative am ount o f air ma nifest s as increa si ng
whitenes s
Imaging in ALI/ARDSImaging in ALI/ARDSQuantitative CTQuantitative CTImaging in ALI/ARDSImaging in ALI/ARDSQuantitative CTQuantitative CT
Hyperinflated(~ > -900 HU)
Normal Aeration(~ - 500 to -900 HU)( 500 to 900 HU)
Poorly aerated(~ -100 to -500 HU)
Non aerated(~ -100 to 100 HU)
Imaging in ALI/ARDS Imaging in ALI/ARDS Categorising lung CT patternsCategorising lung CT patternsImaging in ALI/ARDS Imaging in ALI/ARDS Categorising lung CT patternsCategorising lung CT patterns
1 Gattinoni L et al. What has computed tomography taught us about the acute respiratory distress syndrome Am J Respir Crit Care Med 2001;164:1701-1711
Imaging in ALI/ARDSImaging in ALI/ARDSPathophysiological RelationshipsPathophysiological RelationshipsImaging in ALI/ARDSImaging in ALI/ARDSPathophysiological RelationshipsPathophysiological Relationships
LOW COMPLIANCE
1 Gattinoni L et al. What has computed tomography taught us about the acute repiratory distress syndrome Am J Respir Crit Care Med 2001;164:1701-1711
Imaging in ALI/ARDSImaging in ALI/ARDSLung RecruitmentLung RecruitmentImaging in ALI/ARDSImaging in ALI/ARDSLung RecruitmentLung Recruitment
1 Gattinoni L et al. Lung recruitment in patients with the acute repiratory distress syndrome N Engl J Med2006;354:17011775-1786
Imaging in ALI/ARDSImaging in ALI/ARDSLung RecruitmentLung RecruitmentImaging in ALI/ARDSImaging in ALI/ARDSLung RecruitmentLung Recruitment
1 Gattinoni L et al. Lung recruitment in patients with the acute repiratory distress syndrome N Engl J Med2006;354:17011775-1786
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Imaging in ALI/ARDSImaging in ALI/ARDSWhy the AP Gradient ?Why the AP Gradient ?Imaging in ALI/ARDSImaging in ALI/ARDSWhy the AP Gradient ?Why the AP Gradient ?
Pelosi P et al. Vertical gradient of regional inflation in adult respiratory distress syndrome Am J Respir Crit Care Med1994;149:8-13
Imaging in ALI/ARDSImaging in ALI/ARDSWhy the AP Gradient A Normal Phenomenon?Why the AP Gradient A Normal Phenomenon?Imaging in ALI/ARDSImaging in ALI/ARDSWhy the AP Gradient A Normal Phenomenon?Why the AP Gradient A Normal Phenomenon?
Imaging in ALI/ARDSImaging in ALI/ARDSCardiac CompressionCardiac CompressionImaging in ALI/ARDSImaging in ALI/ARDSCardiac CompressionCardiac Compression
Malbouisson LM et al. Role of the heart in the loss of aeration characterizing lower lobes in acute respiratory distress sndrome Am J Respir Crit Care Med 2000;161:2005-2012
Imaging in ALI/ARDSImaging in ALI/ARDSCardiac CompressionCardiac CompressionImaging in ALI/ARDSImaging in ALI/ARDSCardiac CompressionCardiac Compression
Malbouisson LM et al. Role of the heart in the loss of aeration characterizing lower lobes in acute respiratory distress sndrome Am J Respir Crit Care Med 2000;161:2005-2012
Imaging in ALI/ARDSImaging in ALI/ARDSCardiac Compression Effects of Prone PositioningCardiac Compression Effects of Prone PositioningImaging in ALI/ARDSImaging in ALI/ARDSCardiac Compression Effects of Prone PositioningCardiac Compression Effects of Prone Positioning
Albert RK et al. The prone position eliminates compression of the lungs by the heart Am J Respir Crit Care Med2000;161:1660-1665
Imaging in ALI/ARDSImaging in ALI/ARDSBeneficial Effects of Dependent Atelectasis ?Beneficial Effects of Dependent Atelectasis ?Imaging in ALI/ARDSImaging in ALI/ARDSBeneficial Effects of Dependent Atelectasis ?Beneficial Effects of Dependent Atelectasis ?
VENTRAL“Unprotected”
Desai SR et al. Acute respiratory distress syndrome: CT abnormalities at long-term follow-up Radiology 1999;210:29-35
DORSAL“Protected”
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Imaging in ALI/ARDS Imaging in ALI/ARDS Lung Sequelae in SurvivorsLung Sequelae in SurvivorsImaging in ALI/ARDS Imaging in ALI/ARDS Lung Sequelae in SurvivorsLung Sequelae in Survivors
Desai SR et al. Acute respiratory distress syndrome: CT abnormalities at long-term follow-up Radiology 1999;210:29-35
Imaging in ALI/ARDS Imaging in ALI/ARDS Lung Sequelae in SurvivorsLung Sequelae in SurvivorsImaging in ALI/ARDS Imaging in ALI/ARDS Lung Sequelae in SurvivorsLung Sequelae in Survivors
Desai SR et al. Acute respiratory distress syndrome: CT abnormalities at long-term follow-up Radiology 1999;210:29-35
Imaging in ALI/ARDS Imaging in ALI/ARDS Lung Sequelae in SurvivorsLung Sequelae in SurvivorsImaging in ALI/ARDS Imaging in ALI/ARDS Lung Sequelae in SurvivorsLung Sequelae in Survivors
Desai SR et al. Acute respiratory distress syndrome: CT abnormalities at long-term follow-up Radiology1999;210:29-35
Imaging in ALI/ARDS Imaging in ALI/ARDS Fibrosis in ARDSFibrosis in ARDSImaging in ALI/ARDS Imaging in ALI/ARDS Fibrosis in ARDSFibrosis in ARDS
Ichikado K et al. Acute interstitial pneumonia: comparison of high-resolution computed tomography findings between survivors and nonsurvivors Am J Respir Crit Care Med 2002;165:1551-1556
Imaging in ALI/ARDS Imaging in ALI/ARDS Fibrosis in ARDSFibrosis in ARDSImaging in ALI/ARDS Imaging in ALI/ARDS Fibrosis in ARDSFibrosis in ARDS
Ichikado K et al. Acute interstitial pneumonia: comparison of high-resolution computed tomography findings between survivors and nonsurvivors Am J Respir Crit Care Med 2002;165:1551-1556
Imaging in ALI/ARDS Imaging in ALI/ARDS Early Fibrosis in ARDSEarly Fibrosis in ARDSImaging in ALI/ARDS Imaging in ALI/ARDS Early Fibrosis in ARDSEarly Fibrosis in ARDS
N-TERMINAL PROCOLLAGEN PEPTIDE III
Marshall RP et al. Fibroproliferation occurs early in acute respiratory distress syndrome and impacts on outcome Am J Respir Crit Care Med 2000;162:1783-1788
MITOGENIC ACTIVITY OF BALF in ARDS vs CONTROLS
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Imaging in ALI/ARDSImaging in ALI/ARDSSome Key QuestionsSome Key QuestionsImaging in ALI/ARDSImaging in ALI/ARDSSome Key QuestionsSome Key Questions
• What is/are the principal roles of CXR, CT, US in the management of patients with ALI/ARDS?in the management of patients with ALI/ARDS?
• Does CT add anything…?
• Is there any prognostic information in imaging tests?
Imaging in ALI/ARDS Imaging in ALI/ARDS Fibrosis and Prognosis in ARDSFibrosis and Prognosis in ARDSImaging in ALI/ARDS Imaging in ALI/ARDS Fibrosis and Prognosis in ARDSFibrosis and Prognosis in ARDS
Ichikado K et al. Acute interstitial pneumonia: comparison of high-resolution computed tomography findings between survivors and nonsurvivors Am J Respir Crit Care Med 2002;165:1551-1556
Imaging in ALI/ARDS Imaging in ALI/ARDS Fibrosis and Prognosis in ARDSFibrosis and Prognosis in ARDSImaging in ALI/ARDS Imaging in ALI/ARDS Fibrosis and Prognosis in ARDSFibrosis and Prognosis in ARDS
Ichikado K et al. Acute interstitial pneumonia: comparison of high-resolution computed tomography findings between survivors and nonsurvivors Am J Respir Crit Care Med 2002;165:1551-1556
Imaging in ALI/ARDS Imaging in ALI/ARDS Fibrosis and Prognosis in ARDSFibrosis and Prognosis in ARDSImaging in ALI/ARDS Imaging in ALI/ARDS Fibrosis and Prognosis in ARDSFibrosis and Prognosis in ARDS
Ichikado K et al. Acute interstitial pneumonia: comparison of high-resolution computed tomography findings between survivors and nonsurvivors Am J Respir Crit Care Med 2002;165:1551-1556
Imaging in ALI/ARDS Imaging in ALI/ARDS The Unanswered Questions The Unanswered Questions Imaging in ALI/ARDS Imaging in ALI/ARDS The Unanswered Questions The Unanswered Questions
Morphological differences between ALI and ARDS?
If so, do these predict outcome, duration on ventilator?
Prediction of likely steroid-responsiveness ?
Imaging in ALI/ARDS Imaging in ALI/ARDS Closing RemarksClosing RemarksImaging in ALI/ARDS Imaging in ALI/ARDS Closing RemarksClosing Remarks
Imaging tests are integral to the management of critically-ill patients
Plain chest radiography is the “workhorse” investigation; routine probably acceptable for ICU patients…
CT (+ others) useful supporting role
CT continues to provide pathophysiological and prognostic insights in lung injury
